Section J Health Conditions Falls Evaluate a resident s fall

1
Section JHealth Conditions
2
Objectives1

• State the intent of Section J Health Conditions.
• Identify health conditions assessed in Section J
  that affect a residents functional status and
  quality of life.
• Describe how to conduct the Pain Assessment
  interview.

3
Objectives2

• Describe how to conduct the assessment for other
  health conditions including history of falls,
  shortness of breath, and tobacco use.
• Code Section J correctly and accurately.

4
Intent of Section J

• Document health conditions that impact a
  residents functional status and quality of life
• Pain
• Dyspnea
• Tobacco use
• Prognosis
• Problem conditions
• Falls

5
Pain Assessment

• Consists of an interview with resident.
• Conduct a staff assessment only if resident is
  unable to participate in the interview.
• Pain items assess
• Presence of pain
• Frequency of pain
• Effect on function
• Intensity
• Management
• Control

6
Item J0100Pain Management
7
J0100 Importance

• Pain can cause suffering and is associated with
• Inactivity
• Social withdrawal
• Depressed mood
• Functional decline
• Pain can interfere with participation in
  rehabilitation.
• Effective pain management interventions can help
  to avoid these adverse outcomes.

8
J0100 Conduct the Assessment

• Determine what, if any, pain management
  interventions the resident received during the
  look-back period.
• Review the medical record.
• Interview staff and direct caregivers.

9
J0100 Assessment Guidelines

• The look-back period is 5 days.
• Include information from all disciplines.
• Determine all interventions provided to the
  resident.
• Answer these items even if resident denies pain.

10
J0100A Scheduled Pain Medication Regimen Coding
Instructions

• Code 0. No if medical record does not contain
  documentation that a scheduled pain medication
  was received.
• Code 1. Yes if medical record contains
  documentation that a scheduled pain medication
  was received.

11
J0100B Received PRN Pain Medications Coding
Instructions

• Code 0. No if record does not contain
  documentation that a PRN medication was received
  or offered.
• Code 1. Yes if record contains documentation that
  a PRN medication was either received OR offered
  but was declined.

12
J0100C Received Non-Medication Intervention
Coding Instructions

• Code 0. No if medical record does not contain
  documentation that a non-medication pain
  intervention was received.
• Code 1. Yes if medical record contains
  documentation that
• Non-medication pain intervention scheduled as
  part of the care plan.
• Intervention actually received and assessed for
  efficacy.

13
J0100 Scenario

• The residents medical record documents that she
  received the following pain management in the
  past 5 days
• Hydrocodone/ acetaminophen 5/ 500 1 tab PO every
  6 hours. Discontinued on day 1 of look-back
  period.
• Acetaminophen 500mg PO every 4 hours. Started on
  day 2 of look-back period.
• Cold pack to left shoulder applied by PT BID. PT
  notes that resident reports significant pain
  improvement after cold pack applied.

14
J0100 Scenario Coding1

• Code J0100A as 1. Yes.
• The medical record indicated that the resident
  received a scheduled pain medication during the
  5-day look-back period.
• Code J0100B as 0. No.
• No documentation was found in the medical record
  that the resident received or was offered and
  declined any PRN medications during the 5-day
  look-back period.

15
J0100 Scenario Coding2

• Code J0100C as 1. Yes.
• The medical record indicates that the resident
  received scheduled non-medication pain
  intervention (cold pack to the left shoulder)
  during the 5-day look-back period.

16
J0100 Pain ManagementPractice

• The residents medical record includes the
  following pain management documentation
• MS-Contin (morphine sulfate controlled-release)
  15 mg PO Q 12 hours.
• Resident refused every dose of medication during
  the 5-day look-back period.
• No other pain management interventions were
  documented.

17
How should J0100A be coded?

• Code 0. No.
• Code 1. Yes.

18
J0100A Coding

• The correct coding is 0. No.
• The medical record documented that the resident
  did not receive scheduled pain medication during
  the 5-day look-back period.
• Residents may refuse scheduled medications.
• Medications are not considered received if the
  resident refuses the dose.

19
How should J0100B be coded?

• Code 0. No.
• Code 1. Yes.

20
J0100B Coding

• The correct coding is 0. No.
• The medical record contained no documentation
  that the resident received or was offered and
  declined any PRN medications during the 5-day
  look-back period.

21
How should J0100C be coded?

• Code 0. No.
• Code 1. Yes.

22
J0100C Coding

• The correct coding is 0. No.
• The medical record contains no documentation that
  the resident received non-medication pain
  intervention during the 5-day look-back period.

23
Item J0200Should Pain Assessment Interview Be
Conducted?
24
J0200 Importance

• Most residents capable of communicating can
  answer questions about how they feel.
• Obtaining information about pain directly from
  the resident is more reliable and accurate than
  observation alone for identifying pain.
• Use staff observations for pain behavior only if
  a resident cannot communicate.
• Verbally
• With gestures
• In writing

25
J0200 Conduct the Assessment

• Determine whether resident is understood at
  least sometimes.
• Review A1100 to determine whether resident needs
  or wants an interpreter.
• Make every effort to have an interpreter present
  if needed or requested.

26
J0200 Assessment Guidelines

• Skip to J1100 if the resident is comatose.
• B0100 is coded 1. Yes.

27
J0200 Coding Instructions

• Code 0. No if resident is rarely/ never
  understood or an interpreter is required but not
  available.
• Code 1. Yes if resident is at least sometimes
  understood and an interpreter is present or not
  required.

28
Item J0300- J0600Pain Assessment Interview
29
Importance of Pain Assessment1

• Effects of unrelieved pain impact the individual.
• Functional decline
• Complications of immobility
• Skin breakdown
• Infections
• Pain significantly adversely affects quality of
  life.
• Depressed mood
• Diminished self-confidence and self-esteem
• Increase in behavior problems, particularly for
  cognitively-impaired residents

30
Importance of Pain Assessment2

• Some older adults limit their activities in
  order to avoid having pain.
• Their report of lower pain frequency may reflect
  their avoidance of activity more than it reflects
  adequate pain management.

31
Pain Assessment Interview

• Interview any resident not screened out by
  J0200.
• The interview consists of 4 questions.
• Begins with the primary question.
• J0300 Pain Presence
• Includes 3 follow-up items.
• J0400 Pain Frequency
• J0500 Pain Effect on Function
• J0600 Pain Intensity

32
Pain Assessment InterviewGuidelines1

• The look-back period for all pain interview items
  is 5 days.
• Conduct the interview close to the end of the
  5-day look-back period.
• Skip to the Staff Assessment if the resident is
  unable to answer J0300 Pain Presence.
• Stop the interview and skip to the Staff
  Assessment if the resident is unable to answer
  J0400 Pain Frequency.

33
Pain Assessment InterviewGuidelines2

• Ask each question in order.
• Use other terms for pain or follow-up
  discussion if the resident seems unsure or
  hesitant.
• Code 9 if the resident refuses to answer a
  question and move on to the next question.
• If the resident is unsure about whether pain
  occurred during the look-back period
• Prompt resident to think about the most recent
  episode.
• Try to determine whether it occurred during the
  look-back period.

34
Conduct the Interview

• Establish a conducive environment.
• Use an interpreter if needed.
• Make sure the resident can hear you.
• Explain the reason for the interview.
• Explain the response choices.
• Show responses in large font as appropriate.
• Allow resident to write responses if needed.

35
Item J0300Pain Presence
36
J0300 Pain Presence Conduct the Assessment/
Guidelines

• Ask the question as written.
• Code for the presence or absence of pain
  regardless of pain management efforts.
• Rates of self-reported pain are higher than
  observed rates.

37
J0300 Coding Instructions1

• Code 0. No.
• Resident responds no to presence of pain.
• Even if resident received pain management
  interventions.
• Interview is complete.
• Skip to J1100 Shortness of Breath.
• Code 1. Yes.
• Resident responds yes to presence of pain
  during the look-back period.
• Continue with the pain assessment interview.

38
J0300 Coding Instructions2

• Code 9. Unable to answer.
• Is unable to answer.
• Does not respond.
• Gives a nonsensical response.
• Skip to the Staff Assessment for Pain (J0800).

39
J0300 Scenario

• When asked about pain, Mrs. S. responds, No. I
  have been taking the pain medication regularly,
  so fortunately I have had no pain.

40
J0300 Scenario Coding

• Code J0300 as 0. No.
• Mrs. S. reports having no pain during the
  look-back period.
• Even though she received pain management
  interventions during the look-back period, the
  item is coded No because there was no pain.
• Skip to J1100. Shortness of Breath.

41
J0300 Practice 1

• When asked about pain, Mr. T. responds, No pain,
  but I have had a terrible burning sensation all
  down my leg.

42
How should J0300 be coded?

• Code 0. No.
• Code 1. Yes.
• Code 9. Unable to answer.

43
J0300 Practice 1 Coding

• The correct coding is 1. Yes.
• Although Mr. T.s initial response is no, the
  comments indicate that he has experienced pain
  (burning sensation) during the look-back period.

44
Item J0400Pain Frequency
45
J0400 Pain FrequencyConduct the Assessment

• Ask the question exactly as written.
• May use cue cards to present response options.

46
J0400 Pain FrequencyAssessment Guidelines

• Do not offer definitions of response options.
• Residents response should be based on the
  residents interpretation of the frequency
  options.
• Use echoing to help clarify the preferred option
  if the resident does not respond according to the
  response scale.
• Stop the interview and skip to J0800 to complete
  the Staff Assessment for Pain if the resident is
  unable to respond to this item.

47
J0400 Coding Instructions

• Code the residents response.
• If the resident has difficulty choosing between
  two responses
• Use echoing to help resident clarify the
  response.
• Code the more frequent of the two responses.

48
J0400 Scenario

• When asked about pain, Ms. M. responds, I would
  say rarely.
• Since I started using the patch, I dont have
  much pain at all, but four days ago the pain came
  back.
• I think they were a bit overdue in putting on the
  new patch, so I had some pain for a little while
  that day.

49
J0400 Scenario Coding

• Code J0400 as 4. Rarely.
• Ms. M. selected the rarely response option.

50
J0400 Practice 1

• When asked about pain, Miss K. responds
• I cant remember. I think I had a headache a few
  times in the past couple of days, but they gave
  me Tylenol and the headaches went away.
• Interviewer clarifies by echoing what Miss K.
  said
• Youve had a headache a few times in the past
  couple of days and the headaches went away when
  you were given Tylenol.
• If you had to choose from the answers, would you
  say you had pain occasionally or rarely?
• Miss K. replies Occasionally.

51
How should J0400 be coded?

• Code 1. Almost constantly
• Code 2. Frequently
• Code 3. Occasionally
• Code 4. Rarely
• Code 9. Unable to answer

52
J0400 Practice 1 Coding

• The correct coding is 3. Occasionally.
• After the interviewer clarified the residents
  choice using echoing, the resident selected a
  response option.

53
J0400 Practice 2

• When asked about pain, Mr. J. responds
• I dont know if it is frequent or occasional.
• My knee starts throbbing every time they move me
  from the bed or the wheelchair.
• The interviewer says
• Your knee throbs every time they move you.
• If you had to choose an answer, would you say
  that you have pain frequently or occasionally?
• Mr. J. is still unable to choose between
  frequently and occasionally.

54
How should J0400 be coded?

• Code 1. Almost constantly
• Code 2. Frequently
• Code 3. Occasionally
• Code 4. Rarely
• Code 9. Unable to answer

55
J0400 Practice 2 Coding

• The correct coding is 2. Frequently.
• The interviewer appropriately echoed Mr. J.s
  comment and provided related response options to
  help him clarify which response he preferred.
• Mr. J. remained unable to decide between
  frequently and occasionally.
• The interviewer, therefore, coded for the higher
  frequency of pain.

56
Item J0500Pain Effect on Function
57
J0500 Pain Effect on FunctionConduct the
Assessment

• Ask each question as written.

58
J0500 Pain Effect on FunctionAssessment
Guidelines

• Repeat the response and try to narrow the focus
  of the response if the residents response does
  not clearly indicate yes or no.
• J0500A Over the past 5 days, has pain made it
  hard for you to sleep at night?
• Resident responds, I always have trouble
  sleeping.
• Try to help clarify the response, You always
  have trouble sleeping. Is it your pain that makes
  it hard for you to sleep?

59
J0500 Coding Instructions

• Code the residents response to each question.

60
J0500A Scenario

• Mrs. D. responds, I had a little back pain from
  being in the wheelchair all day, but it felt so
  much better when I went to bed. I slept like a
  baby.

61
J0500A Scenario Coding

• Code J0500A as 0. No.
• Mrs. D. reports no sleep problems related to
  pain.

62
J0500A Practice 1

• Miss G. responds, Yes, the back pain makes it
  hard to sleep.
• I have to ask for extra pain medicine, and I
  still wake up several times during the night
  because my back hurts so much.

63
How should J0500A be coded?

• Code 0. No.
• Code 1. Yes.
• Code 9. Unable to answer.

64
J0500A Practice 1 Coding

• The correct coding is 1. Yes.
• The resident reports pain-related sleep problems.

65
J0500A Practice 2

• Mr. E. responds, I cant sleep at all in this
  place.
• The interviewer clarifies by saying,
• You cant sleep here.
• Would you say that was because pain made it hard
  for you to sleep at night?
• Mr. E. responds,
• No. It has nothing to do with me. I have no
  pain.
• It is because everyone is making so much noise.

66
How should J0500A be coded?

• Code 0. No.
• Code 1. Yes.
• Code 9. Unable to answer.

67
J0500A Practice 2 Coding

• The correct coding is 0. No.
• Mr. E. reports that his sleep problems are not
  related to pain.

68
J0500B Scenario

• Mrs. N. responds, Yes, I havent been able to
  play the piano, because my shoulder hurts.

69
J0500B Scenario Coding

• Code J0500B as 1. Yes.
• Mrs. N. reports limiting her activities because
  of pain.

70
J0500B Practice 1

• Ms. L. responds, No, I had some pain on
  Wednesday, but I didnt want to miss the shopping
  trip, so I went.

71
How should J0500B be coded?

• Code 0. No.
• Code 1. Yes.
• Code 9. Unable to answer.

72
J0500B Practice 1 Coding

• The correct coding is 0. No.
• Although Ms. L. reports pain, she did not limit
  her activity because of it.

73
J0500B Practice 2

• Mrs. S. responds, I dont know.
• I have not tried to knit since my finger swelled
  up yesterday, because I am afraid it might hurt
  even more than it does now.

74
How should J0500B be coded?

• Code 0. No.
• Code 1. Yes.
• Code 9. Unable to answer.

75
J0500B Practice 2 Coding

• The correct coding is 1. Yes.
• Mrs. S. avoided a usual activity because of fear
  that her pain would increase.

76
Item J0600Pain Intensity
77
J0600 Pain Intensity

• Numeric Rating Scale (scale of 00 to 10)
• Verbal Descriptor Scale
• Complete only one of these items, not both.

78
J0600 Conduct the Assessment

• Read the question and response options slowly.
• Ask the resident to rate his or her worst pain.
• Please rate your worst pain over the last 5 days
  with zero being no pain, and ten as the worst
  pain you can imagine.
• Please rate the intensity of your worst pain
  over the last 5 days.
• Use cue cards to show response options if needed.

79
J0600 Assessment Guidelines

• The look-back period is 5 days.
• Try to use the same scale used on prior
  assessments.
• If a resident is unable to answer using one
  scale, try the other scale.
• The resident may answer three ways
• Verbally
• In writing
• Both

80
J0600A Numeric Rating ScaleCoding Instructions

• Code as a two-digit value.
• Use a leading zero for values less than 10.
• Enter 99 if unable to answer or does not answer.
• Leave the response for J0600B blank.

81
J0600B Verbal Descriptor ScaleCoding Instructions

• Code as a one-digit value.
• Enter 9 if unable to answer or does not answer.
• Leave the response for J0600A blank.

82
J0600 Scenario 1

• The nurse asks Ms. T. to rate her pain on a
  scale of 0 to 10.
• Ms. T. states that she is not sure, because she
  has shoulder pain and knee pain, and sometimes it
  is really bad, and sometimes it is OK.
• The nurse reminds Ms. T. to think about all the
  pain she had during the last 5 days and select
  the number that describes her worst pain.
• She reports that her pain is a 6.

83
J0600 Scenario 1 Coding

• Code J0600A as 06.
• The resident said her pain was 6 on the 0 to 10
  scale.

84
J0600 Scenario 2

• The nurse asks Mr. R. to rate his pain using the
  verbal descriptor scale.
• He looks at the response options presented using
  a cue card and says his pain is severe
  sometimes, but most of the time it is mild.

85
J0600 Scenario 2 Coding

• Code J0600B as 3. Severe.
• The resident said his worst pain was Severe.

86
Section JPain Assessment Interview Activity
87
Activity Instructions

• Turn to Section J items J0300 - J0600 in the MDS
  3.0 instrument.
• Watch the Pain Interview video.
• Code the interview in the MDS 3.0.

88
Pain AssessmentInterview Video
The Video on Interviewing Vulnerable Elders
(VIVE) was funded by the Picker Institute and
produced by the UCLA/JH Borun Center.  DVD copies
can be ordered from the Pioneer Network.
89
Pain AssessmentInterview Coding

• J0300 1. Yes
• J0400 1 Almost constantly
• J0500A (sleep) 1. Yes
• J0500B (activities) 1. Yes
• J0600A Numeric Rating Scale code 08

90
Item J0700Should the Staff Assessment for
PainBe Conducted
91
J0700 Importance

• Resident interview for pain is preferred because
  it improves the detection of pain.
• A small percentage of residents is unable or
  unwilling to complete the pain interview.
• Persons unable to complete the pain interview may
  still have pain.

92
J0700 Conduct the Assessment

• Review the residents responses to J0200 -
  J0400.
• Determine if the pain assessment interview was
  completed.
• J0300 Presence of Pain coded 0. No.
• OR
• J0300 Presence of Pain coded 1. Yes.
• J0400 Pain Frequency is answered.

93
J0700 Coding Instructions

• Code 0. No.
• Resident completed the Pain Assessment Interview.
  
• Skip to J1100 Shortness of Breath (dyspnea).
• Code 1. Yes.
• Resident unable to complete the Pain Assessment
  Interview.
• Continue to J0800 Indicators of Pain or Possible
  Pain.

94
Items J0800 J0850Staff Assessment for Pain
95
J0800/ J0850 Importance1

• Residents who cannot verbally communicate about
  their pain are at particularly high risk for
  underdetection and undertreatment of pain.
• Severe cognitive impairment may affect ability
  of residents to communicate verbally.
• Limits availability of self-reported information
  about pain.
• Fewer complaints may not mean less pain.
• Individuals unable to communicate verbally may
  be more likely to use alternative methods of
  expression to communicate pain.

96
J0800/ J0850 Importance2

• Some verbal complaints of pain may be made and
  should be taken seriously.
• Unrelieved pain adversely affects function and
  mobility, contributing to

• Dependence
• Skin breakdown

• Contractures
• Weight loss

• Pain significantly adversely affects quality of
  life and is tightly linked to depressed mood,
  diminished self-confidence and self-esteem, as
  well as to an increase in behavior problems.

97
Indicators of Pain1

• Non-Verbal Sounds include but not limited to

• Vocal Complaints of Pain include but not limited
  to

• That hurts.
• Ouch.
• Stop.

98
Indicators of Pain2

• Facial Expressions include but not limited to

• Grimaces
• Winces
• Wrinkled forehead

• Furrowed brow
• Clenched teeth or jaw

• Protective Body Movements or Gestures include but
  not limited to

• Bracing
• Guarding
• Rubbing/ massaging a body part

• Clutching/ holding a body part during movement

99
J0800 Conduct the Assessment

• Review the medical record.
• Look for documentation of indicators of pain.
• Confirm presence of indicators of pain with
  direct care staff on all shifts who work with
  resident during ADLs.
• Interview staff.
• Question staff who observe or assist the
  resident.
• Ask about presence of each indicator not in the
  record.
• Observe the resident.

100
J0800 Assessment Guidelines

• The look-back period is 5 days.
• Some symptoms may be related to pain
• Behavior change
• Depressed mood
• Rejection of care
• Decreased participation in activities
• Do not report these symptoms here as pain
  screening items.

101
J0800 Coding Instructions

• Check all indicators of pain that apply.
• Based on staff observation of indicators of pain.
• Check Z if no indicators of pain are observed.

102
J0800 Scenario

• Mr. P. has advanced dementia and is unable to
  verbally communicate.
• A note in his medical record documents that he
  has been awake during the last night crying and
  rubbing his elbow.
• When you go to his room to interview the
  certified nurse aide (CNA) caring for him, you
  observe Mr. P. grimacing and clenching his
  teeth.
• The CNA reports that he has been moaning and said
  ouch when she tried to move his arm.

103
J0800 Scenario Coding

• Mr. P. has demonstrated
• Non-verbal sounds (crying and moaning)
• Vocal complaints of pain (ouch)
• Facial expression of pain (grimacing and clenched
  teeth)
• Protective body movements (rubbing his elbow)

104
J0850 Frequencyof Pain Indicators

• Assessment of pain frequency provides
• Basis for evaluating treatment need and response
  to treatment
• Information to aide in identifying optimum timing
  of treatment
• Interview staff and direct caregivers.
• Determine number of days the resident either
  complained of pain or showed evidence of pain
  during the look-back period.
• The look-back period is 5 days.

105
J0850 Coding Instructions

• Code 1 if indicators observed 1-2 days.
• Code 2 if indicators observed 3-4 days.
• Code 3 if indicators observed daily.
• Do not code the number of times that indicators
  of pain were observed or documented.

106
J0850 Scenario

• Mr. M. is an 80-year old male with advanced
  dementia.
• Mr. M. was noted to be grimacing and verbalizing
  ouch over the past 2 days when his right
  shoulder was moved during the 5-day look-back
  period.

107
J0850 Scenario Coding

• Code J0850 as 1. Indicators of pain or possible
  pain observed 1 2 days.
• He has demonstrated vocal complaints of pain
  (ouch) and facial expression of pain
  (grimacing) on 2 of the last 5 days.

108
Item J1100Shortness of Breath
109
J1100 Importance

• Can be an extremely distressing symptom to
  residents.
• Can lead to decreased interaction and quality of
  life.
• Some residents compensate by
• Limiting activity
• Lying flat by elevating the head of the bed
• Do not alert caregivers to the problem.

110
J1100 Conduct the Assessment1

• Interview the resident.
• Ask about shortness of breath or trouble
  breathing.
• If not, ask if shortness of breath occurs during
  certain activities.
• Review the medical record.
• Interview staff on all shifts and family/
  significant other.
• History of shortness of breath
• Allergies
• Other environmental triggers

111
J1100 Conduct the Assessment2

• Observe resident for signs.
• Increased respiratory rate
• Pursed lip breathing
• Prolonged expiratory phase
• Audible respirations
• Gasping for air at rest
• Interrupted speech pattern
• Use of shoulder/ other accessory muscles to
  breathe
• Note whether shortness of breath occurs with
  certain positions or activities.

112
J1100 Assessment Guidelines

• Document any evidence of the presence of a
  symptom of shortness of breath.
• A resident may have any combination of the
  symptoms listed in J1100.

113
J1100 Coding Instructions

• J0800A Exertion
• Limited activity (turning or moving in bed)
• Strenuous activity (transferring, walking,
  bathing)
• Avoids or unable to engage in activity
• J0800C Lying Flat
• Resident attempts or avoids lying flat

114
J1100 Scenario 1

• Mrs. W. has diagnoses of chronic obstructive
  pulmonary disease (COPD) and heart failure.
• She is on 2 liters of oxygen and daily
  respiratory treatments.
• With oxygen she is able to ambulate and
  participate in most group activities.
• She reports feeling winded when going on
  outings that require walking one or more blocks
  and has been observed having to stop to rest
  several times under such circumstances.
• Recently, she describes feeling out of breath
  when she tries to lie down.

115
J1100 Scenario 1 Coding

• Check J1100A with exertion.
• Check J1100C when lying flat.
• Mrs. W. reported being short of breath when lying
  down as well as during outings that required
  ambulating longer distances.

116
J1100 Scenario 2

• Mr. T. has used an inhaler for years.
• He is not typically noted to be short of breath.
• Three days ago, during a respiratory illness, he
  had mild trouble with his breathing, even when
  sitting in bed.
• His shortness of breath also caused him to limit
  group activities.

117
J1100 Scenario 2 Coding

• Check J1100A with exertion.
• Check J1100B when sitting at rest.
• Mr. T. was short of breath at rest and was noted
  to avoid activities because of shortness of
  breath.

118
Item J1300Current Tobacco Use
119
J1300 Importance

• The negative effects of smoking can shorten life
  expectancy.
• Create health problems that interfere with daily
  activities and adversely affect quality of
  life.
• Includes tobacco used in any form.

120
J1300 Conduct the Assessment

• Ask the resident if used tobacco in any form
  during the look-back period.
• Review the medical record and interview staff
  about indications of tobacco use.
• Resident is unable to answer.
• Resident indicates that he or she did not use
  tobacco during the look-back period.

121
J1300 Coding Instructions

• Code 0. No if there are no indications of use
  during the look-back period.
• Code 1. Yes if the resident or any other source
  indicates tobacco use of some form.

122
Item J1400Prognosis
123
J1400 Importance

• Residents with conditions or diseases that may
  result in a life expectancy of less than 6
  months
• Have special needs.
• May benefit from palliative or hospice services
  in the nursing home.

124
J1400 Conduct the Assessment

• Review medical record for documentation.
• Condition or chronic disease that may result in
  life expectancy of less than 6 months
• Terminal illness
• Indication of hospice services
• Request documentation in the medical record if
  physician or other authorized, licensed staff as
  permitted by state law states that resident life
  expectancy is less than 6 months.

125
J1400 Coding Instructions

• Code 1. Yes only if the medical record contains
  documentation of terminal illness, hospice
  services, or condition/ chronic disease.

126
J1400 Scenario

• Mrs. T. has a diagnosis of heart failure.
• During the past few months, she has had three
  hospital admissions for acute heart failure.
• Her heart has become significantly weaker despite
  maximum treatment with medications and oxygen.
• Her physician has discussed her deteriorating
  condition with her and her family and has
  documented that her prognosis for survival beyond
  the next couple of months is poor.

127
J1400 Scenario Coding

• Code J1400 as 1. Yes.
• The physician documented that her life expectancy
  is likely to be less than 6 months.

128
Item J1550Problem Conditions
129
J1550 Problem Conditions/ Conduct the Assessment

• Review the medical record
• Interview staff on all shifts.
• Observe the resident.
• Identify any indications of the conditions listed
  in J1550 during the look-back period.
• Further medical assessment may be indicated if
  resident presents with these conditions.
• Code any diagnosis in Section I.

130
J1550 Assessment Guidelines1

• Temperature of 100.4 F (38 C) on admission
  would be considered a fever.
• Dehydration requires at least two indicators
• Takes in less than 1,500 ml of fluids daily.
• Has one or more clinical signs of dehydration.
• Fluid loss exceeds amount of fluids residents
  takes in.

131
J1550 Assessment Guidelines2

• Internal bleeding guidelines
• May be frank or occult.
• Observe clinical indicators.
• Do not code as internal bleeding
• Nosebleeds that are easily controlled
• Menses
• Urinalysis that shows a small amount of red blood
  cells

132
J1550 Coding Instructions

• Check all that apply during the look-back period.

133
Item J1700Fall History on Admission
134
J1700 Importance

• Falls are a leading cause of injury, morbidity,
  and mortality in older adults.
• A previous fall are the most important predictors
  of risk for future falls and injurious falls.
• Persons with a history of falling may limit
  activities because of a fear of falling and
  should be evaluated for reversible causes of
  falling.
• J1700 tracks history of falls and fractures
  related to a fall within the month prior to
  admission and the six months prior to admission.

135
Definition of a Fall

• Unintentional change in position coming to rest
  on the ground, floor, or next lower surface.
• May be witnessed, reported by resident or
  identified by finding resident on the floor or
  ground.
• May occur in any setting.
• Not a result of overwhelming external force.
• Intercepted fall where resident catches himself
  or herself or is intercepted by another person is
  still considered a fall.

136
J1700 Conduct the Assessment

• Ask resident and family/ significant other
• Month prior to admission
• Six months prior to admission
• Review inter-facility transfer information.
• Review all relevant medical records from
  facilities where resident resided in 6 months
  prior to admission.
• Review any other medical records for evidence of
  a fall.

137
J1700 Assessment Guidelines1

• Complete this item only for an
• J1700A documents whether the resident had any
  falls during the month prior to admission.
• J1700B documents whether the resident had any
  falls during the 2 6 months prior to admission.

138
J1700 Assessment Guidelines2

• J1700C documents whether the resident experienced
  a fracture due to fall in 6 months prior to
  admission.
• Documented in medical record, x-ray report, or
  resident history.
• Occurred as direct result of a fall or later
  attributed to a fall.
• Do not include car crashes, pedestrian accidents,
  or impact of person/ object against the resident.

139
J1700 Coding Instructions

• Code 0. No if there is no report or documentation
  of falls or fracture due to falls.
• Code 1. Yes if there is a report or documentation
  of falls or fracture due to falls.
• Code 9. Unable to determine if resident, family
  or significant other cannot provide information
  and documentation is inadequate.

140
J1700 Scenario 1

• On admission interview, Mrs. J. is asked about
  falls and says she has "not really fallen."
• However, she goes on to say that when she went
  shopping with her daughter about 2 weeks ago, her
  walker got tangled with the shopping cart and she
  slipped down to the floor.

141
J1700 Scenario 1 Coding

• J1700A would be coded 1. Yes.
• Falls caused by slipping meet the definition of
  falls.

142
J1700 Scenario 2

• Ms. P. has a history of a "Colles fracture" of
  her left wrist about 3 weeks before nursing home
  admission.
• Her son recalls that the fracture occurred when
  Ms. P. tripped on a rug and fell forward on her
  outstretched hands.

143
J1700 Scenario 2 Coding

• J1700A would be coded 1. Yes.
• J1700C would be coded 1. Yes.
• Ms. P. had a fall-related fracture less than 1
  month prior to entry.

144
J1700 Scenario 3

• Mr. O.s hospital transfer record includes a
  history of osteoporosis and vertebral
  compression fractures.
• The record does not mention falls, and Mr. O.
  denies any history of falling.

145
J1700 Scenario 3 Coding

• J1700C would be coded 0. No.
• The fractures were not related to a fall.

146
Items J1800 J1900Any Falls Number of Falls
Since Admission or Prior Assessment (OBRA or
PPS) Whichever is More Recent
147
J1800/ J1900 Importance

• Falls are a leading cause of morbidity and
  mortality among nursing home residents.
• Falls result in serious injury, especially hip
  fractures.
• Fear of falling can limit an individuals
  activity and negatively impact quality of life.

148
J1800/ J1900Conduct the Assessment

• Determine if any falls occurred during the
  look-back period and level of injury for each
  fall.
• Review the medical record.
• Physician/ authorized, licensed staff notes
• Nursing, therapy, and nursing assistant notes
• Review all available sources.
• Nursing home incident reports
• Fall logs
• Medical records generated in any health care
  setting
• Ask the resident and family/ significant other.

149
J1800/ J1900Assessment Guidelines1

• Review the time period from the day after the ARD
  of the last MDS assessment to ARD of the current
  MDS assessment.
• Review the time period since the admission date
  to the ARD if this is an admission assessment
  (A310E 1).
• Code falls that occur in any setting
• Community
• Nursing home
• Acute hospital

150
J1800/ J1900Assessment Guidelines2

• Code falls reported by the resident, family, or
  significant other even if not documented in the
  medical record.
• Code the level of injury for each fall that
  occurred during the look-back period.
• If the resident has multiple injuries in a single
  fall, code for the highest level of injury.

151
J1800 Any Falls Since Admission or Prior
Assessment Coding Instructions

• Code whether the resident had any falls during
  the look-back period.
• Skip to K0100 Swallowing Disorder if 0. No.

152
J1800 Scenario

• An incident report describes an event in which
  Mr. S was walking down the hall and appeared to
  slip on a wet spot on the floor.
• He lost his balance and bumped into the wall but
  was able to grab onto the hand rail and steady
  himself.

153
J1800 Scenario Coding

• Code J1800 as 1. Yes.
• This would be considered an intercepted fall.
• An intercepted fall is coded as a fall.

154
J1900 Number of Falls Since Admissionor Prior
Assessment Coding Instructions

• Enter a code for each item to indicate the number
  of falls resulting in that level of injury.
• Code the level of injury for each fall that
  occurred during the look-back period.
• Code each fall only once.

155
J1900 Scenario 1

• A nursing note states that Mrs. K slipped out of
  her wheelchair onto the floor while at the dining
  room table.
• Before being assisted back into her chair, an
  assessment was completed that indicated no
  injury.

156
J1900 Scenario 1 Coding

• Code J1900A as 1. One fall with no injury.
• Slipping to the floor is a fall.
• No injury is noted.

157
J1900 Scenario 2

• A nurses note describes a resident who, while
  being treated for pneumonia, climbed over his
  bedrails and fell to the floor.
• He had a cut over his left eye and some swelling
  on his arm.
• He was sent to the emergency room, where X-rays
  revealed a fractured arm.
• Neurological checks revealed no changes in mental
  status.

158
J1900 Scenario 2 Coding

• Code J1900C as 1. One fall with major injury.
• The resident received multiple injuries in this
  fall.
• Code each fall for the highest severity level
  only.
• Code each fall only once.

159
Section JSummary
160
Pain Assessment

• Complete a pain assessment interview if at all
  possible.
• When determining the assessment for pain
  intensity, use either the Verbal Descriptor Scale
  or the Numeric Rating Scale, not both.
• Complete the staff assessment for pain only if an
  interview cannot be completed.
• Complete a pain assessment even if the resident
  denies pain.

161
Additional Assessments

• Complete the assessment for additional health
  conditions.
• Shortness of breath
• Tobacco use
• Prognosis
• Problem conditions (vomiting, fever, internal
  bleeding, potential indicators of dehydration)

162
Falls

• Evaluate a residents fall history.
• Interview resident, family, and staff.
• Identify falls that occurred in the facility and
  other settings.
• Consult all available sources.
• Determine if any injuries occurred due to a fall.
• Code the level of injury that occurred since
  admission or the prior assessment.